Relative adrenal insufficiency: an identifiable entity in nonseptic critically ill patients?
Relative adrenal insufficiency: an identifiable entity in nonseptic critically ill patients?
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DOI：
10.1111/j.1365-2265.2007.02814.x
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发表时间：
2007-05-01
影响因子：
3.2
通讯作者：
Groeneveld, A. B. Johan
中科院分区：
文献类型：
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作者：
de Jong, Margriet F. C.;Beishuizen, Albertus;Groeneveld, A. B. Johan
目的探讨重症监护病房（ICU）非感染性低血压患者的相对肾上腺功能不全（RAI）诊断。设计对某大学医院内科-外科ICU进行回顾性研究。172例非脓毒症ICU患者（51%创伤或手术后），因bbbb60小时低血压或血管加压/肌力治疗接受短时间250 μ g ACTH试验。在测试当天，计算简化急性生理评分II （SAPS II）和顺序器官衰竭评估（SOFA）评分，以评估疾病严重程度。记录28天前ICU死亡率。使用受试者工作特征曲线建立基线皮质醇、升高和峰值的最佳判别水平。这些因素和皮质类固醇治疗（n = 112,65 %）以及其他变量，通过多重逻辑回归和Cox比例风险回归分析进行检验，以找到ICU至28天死亡率的独立预测因素。结果28天前ICU死亡率为23%。非幸存者的SAPS II和SOFA评分较高。基线皮质醇水平与白蛋白水平和SAPS II直接相关。在多变量分析中，皮质醇基线值低于475 nmol/l和皮质醇升高值< 200 nmol/l预测死亡率，这在很大程度上取决于疾病严重程度，但与白蛋白水平无关。无论ACTH测试结果如何，皮质类固醇（氢化可的松）治疗与预后改善无关。结论在非感染性低血压ICU患者中，低皮质醇/ACTH反应和皮质类固醇治疗与疾病严重程度预测死亡率无关。因此，这些数据反对通过皮质醇/ACTH测试识别RAI，并要求对这些患者进行皮质类固醇替代治疗。
Objective To determine whether relative adrenal insufficiency (RAI) can be identified in nonseptic hypotensive patients in the intensive care unit (ICU).Design Retrospective study in a medical-surgical ICU of a university hospital.Patients One hundred and seventy-two nonseptic ICU patients (51% after trauma or surgery), who underwent a short 250 mu g ACTH test because of > 6 h hypotension or vasopressor/inotropic therapy.Measurements On the test day, the Simplified Acute Physiology Score II (SAPS II) and Sequential Organ Failure Assessment (SOFA) score were calculated to estimate disease severity. The ICU mortality until day 28 was recorded. Best discriminative levels of baseline cortisol, increases and peaks were established using receiver operating characteristic curves. These and corticosteroid treatment (in n = 112, 65%), among other variables, were examined by multiple logistic regression and Cox proportional hazard regression analyses to find independent predictors of ICU mortality until day 28.Results ICU mortality until day 28 was 23%. Nonsurvivors had higher SAPS II and SOFA scores. Baseline cortisol levels correlated directly with albumin levels and SAPS II. In the multivariate analyses, a cortisol baseline > 475 nmol/l and cortisol increase < 200 nmol/l predicted mortality, largely dependent on disease severity but independent of albumin levels. Corticosteroid (hydrocortisone) treatment was not associated with an improved outcome, regardless of the ACTH test results.Conclusion In nonseptic hypotensive ICU patients, a low cortisol/ACTH response and treatment with corticosteroids do not contribute to mortality prediction by severity of disease. The data thus argue against RAI identifiable by cortisol/ACTH testing and necessitating corticosteroid substitution treatment in these patients.